The globalization of drug injecting*

During the last decade, drug injecting has spread spectacularly in the developing world from Lagos to Lahore [1, 2]. Injecting drug use on a significant scale was known in but a handful of developing countries 10 years ago. Of the 121 countries where drug injecting has now been reported [1], about three-quarters would be classified as developing. Apart from Africa, developing countries where drug injecting is neither common nor problematic are the exception these days, rather than the rule. Even in Africa, there are now ominous signs of drug injecting spreading in Nigeria and almost a dozen other countries [1]. While drug injecting has been spreading recently on an unprecedented scale, the consequences of drug injecting have also become increasingly more serious. First, the global epidemic of HIV has transformed drug injecting irrevocably from a somewhat risky behaviour to one with potentially devastating consequences for individuals, their families and communities [3]. Secondly, HIV has alerted public health authorities to other serious blood-borne viral infections, including hepatitis B and C. Thirdly, the serious consequences of uncontrolled epidemics of HIV, and the powerful multiplier effect of HIV epidemics linked to injecting drug use which caused public health authorities to take injecting drug use as a serious public health issue for the first time, distracted these authorities in many countries from the increasing number of deaths among drug injectors, especially from drug overdose. It is estimated that there are now 200 000 deaths per year among the global population of over 8 million drug injectors [4]. The numbers of reported deaths has increased over the last decade in such countries as Canada, Norway, Poland, Portugal, Spain, Switzerland, Austria, Belgium, Denmark, France, Germany, Italy, the United Kingdom, Hong Kong, Japan and Saudi Arabia [4]. Data on drug overdose deaths from less developed countries are scant, but it would be surprising if the same trend has not also occurred recently in the developing world. Even in Manipur, India, where injecting drug users are estimated to comprise 2% of the population with HIV seroprevalence in this group reaching 80%, deaths of most young adult males have been attributed by relatives to drug overdose rather than AIDS in early epidemic years [5]. Although illicit drug use in the developed world dominates the scientific literature and international news media, drug use in many industrialized countries has been relatively stable for some years. For example, the average age of drug users in Amsterdam has risen sharply in recent years from 28 to 37 years between 1990 and 1996 [6]. Moreover, the prevalence of injecting among drug users in Amsterdam has declined from 66% in 1986 to 36% in 1998 [7]. Taken together, this suggests that the number of injecting drug users is declining rapidly. What fuelled the diffusion of drug use, the catastrophic transition to more dangerous drugs and the disastrous change to more hazardous routes of administration in developing countries during the 1980s and 1990s? The policy responses to illicit drugs is, by convention, divided into demand and supply reduction. More recently harm reduction has been added, somewhat tentatively, to the official repertoire, although still considered beyond the pale in some powerful circles. However, from Bombay to Brazilia supply and demand enhancement coupled with harm augmentation are far more valid concepts for understanding the realities of illicit drug use in the developing world. Supply enhancement describes the reality of global illicit drug cultivation and production growing steadily at 5–10% per annum for the last decade. Between 1971 and 1999, global opium production grew fivefold to reach 6100 tonnes [8-10], while coca cultivation doubled between 1984 and 1999 to reach 600 000 tonnes [10]. Enthusiastic reports of declining production usually reflect temporary and local reverses, explained most often by poor weather in critical growing areas. The orderly division of the planet into developing countries which produce illicit drugs and developed countries which consume these drugs ceased to exist long ago. As demand for illicit drugs in the developed world has become more saturated and the risks of exporting to these markets has also increased, more and more illicit drugs have found their way to expanding markets in the growing regions. Transit cities have begun to spawn local markets, supplied initially by crumbs from the large international markets. Supply has undoubtedly created demand. Another important factor in supply enhancement has been the major improvement in transport infrastructure in the developing world as highways, ports, containerization and other technological developments have made the task of moving illegal as well as legal commodities much easier [11]. The mighty World Bank-funded highway now under construction, between China and Vietnam passing through Laos and Thailand, may do wonders for economic growth in the region. It would be astonishing if it did not also facilitate trade in injectable drugs and a consequent epidemic of HIV in areas so far less affected by the dual epidemics. Immense profits are now being generated from the illicit drug trade. These are an inevitable consequence of their contraband status in the face of inexorably increasing demand. It would be fatuous to try to understand the astonishing growth of illicit drug markets in recent years without considering the magnitude of the profits of this trade and the reason these profits are so immense. Global annual turnover of the illicit drug trafficking industry has been estimated at $US 500 billion, seven or eight times the total international foreign aid [4]. Profits, estimated at $US 85–350 billion, provide the oxygen for relentless expansion, the search for new customers, new wholesalers and retailers and new products. An interactive relationship between demand and supply seems undeniable. Far from acting as water on the flames of an illicit drug market, prohibition unfortunately appears to have been more like kerosene. Demand enhancement refers to a variety of factors which increase the desire to use drugs. These conditions must make drug traffickers rub their hands in glee. The global increase in disparity of incomes, reduction in support for disadvantaged populations and declining opportunities for employment and education for young people are all conditions conducive to greater demand for illicit drugs. Movement of populations from the countryside to cities has been particularly marked in the developing world in recent times, especially in those volatile countries racked by war, famine and political unrest, but even in those countries where strong economic development has created improving opportunities in the cities. Illicit drug use is generally more evident in countries making the transition from communism to a market economy and also generally in urban areas where drug markets are easier to operate, provide much-needed income, employment and a temporary chemical vacation from intolerable squalor. In the countries comprising the former Soviet Union, the breakdown of governance, rapid development of a large urban underclass living in wretched conditions and the establishment of thousands of new companies with minimal commercial supervision [12] has created ideal conditions for growing drug markets. Heroin has now become the opium of the people. Harm enhancement refers to the tendency for more dangerous drugs to replace less dangerous drugs and more hazardous to replace less hazardous routes of administration. Harm augmentation is very often an unanticipated consequence of intensified supply reduction. In India, use of injectable buprenorphine diverted from medicinal supplies became common after 1991 when supplies of smokeable heroin dried up [13]. In South America, basuco has largely replaced coca leaf in urban areas. Subsequently basuco was often replaced by cocaine hydrochloride, consumed by snorting or injection. Powder cocaine was later replaced by crack, consumed by inhalation. A generation ago in Asia, opium smoked by old men was replaced by heroin injection among young men with catastrophic public health consequences [14]. Opium is easier to detect because it occupies a larger volume, has a stronger smell and smoking pipes are larger than needles and syringes. Anti-opium policies emerged to be not only pro-heroin but also potentially pro-HIV. This transition has not always occurred when law enforcement has been intensified [1], but there was harmful large-scale switching to heroin in South-east Asia following the reclassification of opium as a dangerous drug as early as the 1940s [15]. Again, heroin availability increased markedly after controlled opium availability was restricted in countries as diverse as India (1985), Pakistan (1979), Iran (1979), Bangladesh (1979) and Nepal (late 1970s), while in Laos and Hong Kong risky injecting practices and drug-related HIV has increased minimally [16] because of a tolerance for opium use in the former and easy access to supervised methadone treatment in the latter country [17]. When Colombian drug traffickers were pressured to reduce the quantities of bulky cannabis being exported to the United States, they responded by switching to cocaine, a more compact, lucrative but also more toxic drug [18]. John Erlichman, the notorious Watergate conspirator, played a seminal role in developing the War on Drugs during the Nixon Administration [19]. This offensive, now claimed by Erlichman to have been initiated for short-term domestic political reasons, resulted in far-reaching effects around the world. Erlichman admitted, with admirable but retrospective candour, ‘the people in the federal government . . . know darn well that the massive war they have mounted on narcotics is only going to be effective at the margins. If they don’t know it, they ought to know it’[19]. The War on Drugs may be effective only at the margins, but the unintended negative consequences are probably far more significant than any notional gains. In the developing world during the 1980s and 1990s, the diffusion of drug injecting, the transition to more dangerous drugs and more hazardous routes of administration and the increasingly serious consequences of drug injecting for individuals and communities has occurred while global prohibition has been progressively intensified and free market economic policies implemented almost universally. Despite the high cost, relative ineffectiveness and often-severe unintended negative consequences of supply reduction, drug prohibition remains the global drug policy. Many countries with otherwise very successful HIV policies and programmes fail to implement effective HIV prevention policies and programmes for drug users due to a misperception that these are in conflict with supply control, endangering the lives of millions of drug users, their sex partners and families and other members of their communities [20]. These days, governments call increasingly upon their citizens to accept full responsibility for their lives. Perhaps the time has come when influential governments and powerful international organizations will also have to accept responsibility for the outcomes of their policies.

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